Rational Patient Apathy.

Abstract

Patients with serious or life-threatening illness are frequently asked to make complex, high-stakes medical decisions. The impact of anxiety, low health literacy, asymmetric information and inadequate communication between patients and health care providers, family pressures, rational apathy by health care providers, cognitive biases of both patients and health care providers, and other factors make it quite difficult for patients in these circumstances to process and comprehend the strategic uncertainty and resultant risks and benefits of, and alternatives to, whatever therapeutic or life-prolonging treatment physicians are offering. All of these factors render the classic goal of "informed consent" unachievable in all but the rarest of circumstances: The effort to discuss and evaluate strategic uncertainty, its rational reduction into risks and benefits, and alternatives of treatment for purposes of optimizing decisional outcomes will have genuine intrinsic value only for ultra-rational patients (and physicians). In addition to these alterable barriers to rational decision-making--i.e., barriers that can, in theory, be overcome by ultra-rational patients and physicians with sufficient time and persistent inquiry--there is a second decision-making realm in which the added complexities of bounded rationality, clinical uncertainty and, in particular, of overall Knightian uncertainty provide insurmountable, unalterable barriers to confident rational decision-making. Within this more fundamental human realm of irreducible uncertainty, even ultra-rational, good-Bayesian decision-makers can never confidently calculate a highest-utility treatment option. In order to better describe this secondary realm of unalterable barriers to rational patient choice, including its usually subversive effect on end-of-life decisional behavior, by both average, minimally-rational patients and ultrarational patients, we coin the terms "rational patient apathy" and, relatedly, "rational patient ignorance." Given that confronting the absolute uncertainty inherent in facing one's mortality is cognitively, psychologically and emotionally daunting, and thus largely left unexplored and unpracticed by most patients for most of their healthier decisional lives, rational patient apathy at the sudden onset of a serious or life-threatening illness overwhelmingly defaults to negative decision-making: an affirmative choice to not make any balanced decision on the merits but rather to remain rationally ignorant of some or all aspects of the choice situation. In the context of this persistent patient avoidance of substantive decision-making, empirical evidence demonstrates frequent reversion to a quantity-over-quality approach, allowing health care providers to "do everything" until continued medical intervention reaches the point of obvious medical or economic futility. As a result—and as a largely discounted trade-off of choosing to avoid decisional burdens through non-careful consideration or no consideration at all—the overwhelming result of rational patient apathy in end-of-life decision-making is an irrational calculation and decision unto itself. Not only does rational patient apathy negate the classic (and utopian) goal of informed consent, it also exerts tremendous costs--on patients, on loved ones, on health care providers and on society at-large--in terms of adverse effects, avoidable suffering, constantly recurring decisional commitment costs, and the wasting of scarce economic resources.